Nursing Elites

1. In the immediate postoperative period for a cleft lip repair in a 2-month-old infant, which nursing approach should be the priority?

• A. Remove protective arm devices one at a time for short periods with supervision
• B. Initiate oral feedings when alert
• C. Introduce the parents to the suture line cleansing protocol
• D. Position the infant on the back after feedings throughout the day

Correct answer: A

Rationale: The correct nursing approach in the immediate postoperative period for a cleft lip repair in an infant is to remove protective arm devices one at a time for short periods with supervision. This approach helps prevent injury to the surgical site while ensuring the infant's comfort and safety. Choice B is incorrect as initiating oral feedings immediately after surgery may not be appropriate and could compromise the surgical site. Choice C is incorrect as introducing parents to the suture line cleansing protocol is important but not the immediate priority. Choice D is incorrect as positioning the infant on the back after feedings is not specific to the immediate postoperative period for a cleft lip repair.

2. A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?

• A. Pain related to periosteal injury
• B. Impaired mobility related to bleeding
• C. Parental anxiety related to knowledge deficit
• D. Injury related to intracranial hemorrhage

Correct answer: C

Rationale: The correct nursing diagnosis to guide the plan of care for a newborn with a pronounced cephalic hematoma following a birth in the posterior position is 'Parental anxiety related to knowledge deficit.' This is appropriate because the parents may be worried about the appearance and potential complications of the cephalic hematoma. They may require education and reassurance from the nurse. Choices A, B, and D are incorrect because they do not address the emotional needs of the parents and the knowledge deficit they may have regarding the condition.

3. Which intervention should the public health nurse implement to address one of the leading health indicators of Healthy People 2020?

• A. Lead a weekly water aerobics class for the elderly at a community center.
• B. Teach a class on cultural awareness to nursing students at the university.
• C. Design and implement a no smoking campaign at the local high school.
• D. Write a grant to help provide glucometers to individuals who cannot afford one.

Correct answer: C

Rationale: Designing and implementing a no smoking campaign aligns with the objective of reducing tobacco use, which is one of the leading health indicators of Healthy People 2020. This intervention directly targets a significant public health concern. Leading a water aerobics class, teaching cultural awareness, or providing glucometers, while beneficial in other contexts, do not specifically address the leading health indicators outlined by Healthy People 2020.

4. The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

• A. Extreme fatigue
• B. Increased appetite
• C. Intense itching
• D. Constipation

Correct answer: A

Rationale: Extreme fatigue can be a sign of digitalis toxicity, especially in older adults, and warrants a review of the client's medication levels and potential adjustment. Increased appetite, intense itching, and constipation are not typically associated with digitalis toxicity and do not directly indicate a need for a review of digitalis levels.

5. Community health nurses help influence the health of communities through which of the following actions?

• A. legislating health behavior
• B. recording health status of individuals in a similar geographic region
• C. influencing health status and behavior, and engaging in health promotion
• D. none of the above

Correct answer: C

Rationale: Community health nurses play a crucial role in influencing the health of communities by engaging in health promotion activities and influencing health behaviors. Choice A is incorrect as community health nurses do not legislate health behavior but rather educate and promote healthy behaviors. Choice B is incorrect as while community health nurses may record health data, their main focus is on proactive health promotion and intervention, not just documenting health status. Choice D is incorrect because community health nurses actively work to influence health status and behaviors.

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